Registration Information
Level 4 - Mastering CEREC Anteriors
To expedite the process, please register by phone at 1.866.781.0072
or fill in your answers, print out the form and fax it to 1.480.588.9072
Today's Date: Feb 04, 2012
Course Date:
February 25 - February 26
March 22 - March 23
March 24 - March 25
May 19 - May 20
June 07 - June 08
June 09 - June 10
July 12 - July 13
July 14 - July 15
August 05 - August 06
December 08 - December 09
Doctor's Name:
Mailing Address:
City:
State:
Zip:
Phone:
Fax:
Formal Name of Practice:
What is your CEREC experience level?
I have completed 0 to 50 CEREC restorations
I have completed 50+ CEREC restorations
Email:
Tuition:
$2,950 for doctors
$950 for team members
Full Name
Position
Fee
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2.
3.
4.
5.
6.
7.
Credit Card Payment: MasterCard - VISA - Amex
Credit Card:
Security Code:
Expiration Date:
Name on Card:
